Prior Authorization is required for all Out-of-Network Services. The services below require prior authorization. Please submit supporting clinical documentation with your request so that we can determine medical necessity.

Any service authorizations/pending cases prescribed or authorized before the member’s effective date with CCP.

Please be advised that:

• Authorization requests should be submitted via the PlanLink provider portal and should include all necessary clinical documentation to facilitate the review. Incomplete requests will not be accepted. Providers who are registered to use PlanLink are asked to use the Web Portal when requesting prior authorization of medical services. Until PlanLink access has been granted, providers may in the interim, fax the Community Care Plan - Florida Healthy Kids Prior Auth (PA) Request Form to CCP Utilization Management (UM) Department at
  1-866-930-0969. All services rendered by out-of-network providers require prior authorization from CCP.
• For Behavioral Health services that require prior authorization, providers should contact Carisk Behavioral Health at 1-800-294-8642.
• For PT, OT, ST services that require prior authorization, providers should contact Health Network One (HN1) at 1-888-550-8800.
• For Home Health and DME services that require prior authorization, providers should contact Coastal Care Services, Inc. at 1-833-204-4535.
• For any medication requests under the pharmacy benefit that require prior authorization, providers should fax the Community Care Plan – Florida Healthy Kids Pharmacy Prior Authorization Request form to Magellan Pharmacy services for review of medical necessity.

For your reference below is CCP’s list of Florida Healthy Kids’ services that require prior authorization as of January 1, 2020.

ALL SERVICES RENDERED BY OUT OF NETWORK PROVIDERS REQUIRE PRIOR AUTHORIZATION FROM COMMUNITY CARE PLAN.

FOR BEHAVIORAL HEALTH AND SUBSTANCE USE SERVICES THAT REQUIRE PRIOR AUTHORIZATION, PLEASE CONTACT CARISK BEHAVIORAL HEALTH AT 1-800-294-8642.

ADMISSION INPATIENT and FACILITY- BASED CARE

ELECTIVE MEDICAL INPATIENT ADMISSION

ELECTIVE SURGICAL INPATIENT ADMISSION

INPATIENT ACUTE REHABILITATION ADMISSION

NON-ELECTIVE (EMERGENCY) ADMISSION

SKILLED NURSING FACILITY ADMISSION

SKILLED NURSING FACILITY ADMISSION

ADMISSION HOSPITAL OBSERVATION

ADMISSION / DISCHARGE SAME DAY

HOSPITAL OBSERVATION SERVICES (for any reason)

COSMETIC/ PLASTIC/ RECONSTRUCTIVE PROCEDURES

ADJACENT TISSUE TRANSFER/ REARRANGEMENT/ REPAIR INTEGUMENTARY SYSTEM

BARIATRIC SURGERY

BLADDER REPAIR/ RECONSTRUCTION PROCEDURES

BREAST SURGICAL PROCEDURES (excludes excisions or biopsies)

CANTHOPLASTY

CONSTRUCT BLADDER OPENING

CREATE TEAR SAC DRAIN

DERMATOLOGIC PHOTOCHEMOTHERAPY AND LASER TREATMENT

DESTRUCTION OF LESIONS

EYELID, EXCISION AND REPAIR

EYELID REPAIR PROCEDURES

FOOT and TOES RECONSTRUCTION

GASTRIC NEUROSTIMULATOR PROCEDURES

GASTRIC PROCEDURES (including laparoscopic surgery and revision of anastomosis)

HAND AND FINGERS RECONSTRUCTION

HEAD (SKULL, FACE, TMJ) RECONSTRUCTION

HEART DEFECT REPAIR (STRUCTURAL)

HUMERUS AND ELBOW RECONSTRUCTION

INTRALESIONAL INJECTIONS

KERATOPROSTHESIS

KNEE, ARTHROPLASTY

LIP/ PALATE REPAIR

MASTOID SURGERY

NECK AND THORAX RECONSTRUCTION

NOSE, REPAIR

OCULAR ADNEXA, STRABISMUS SURGERY

PALATE AND UVULA REPAIR

PELVIS and HIP RECONSTRUCTION

PENILE REPAIR

SKIN FLAPS AND GRAFTS

DENTAL CARE IN A FACILITY

Medically necessary dental services are authorized by the FHKC CONTRACTED DENTAL INSURANCE CARRIERS. CCP will be responsible for the prior authorization of the facility and ancillary medical services in the facility.

DIAGNOSTIC IMAGING AND LAB TESTING

CT SCAN

GENETIC TESTING

MRI

PET SCAN

SLEEP STUDY

TRANSVAGINAL US NON-OB

DIALYSIS

HEMODIALYSIS AND PERITONEAL

DURABLE MEDICAL EQUIPMENT (DME):
ALL DME REQUIRES AUTHORIZATION FROM COASTAL CARE SERVICES (1-833-204-4535) WITH THE EXCEPTION OF THE ITEMS LISTED BELOW, WHICH REQUIRE AUTHORIZATION DIRECTLY FROM COMMUNITY CARE PLAN.

DIABETIC SHOES

COCHLEAR DEVICE SYSTEM

PATIENT LIFTS

ELECTIVE INVASIVE PROCEDURES

ABLATE HEART DYSRHYTHM FOCUS (ELECTROPHYSIOLOGICAL PROCEDURES)

ABLATE INFERIOR TURBINATE

ABORTION PROCEDURES (elective)

ADJUST BONE FIXATION DEVICE

ANAL PRESSURE RECORD

ANAL/ URINARY EMG

ARTHROSCOPY ALL BODY AREAS

AV SHUNT/ ANASTOMOSIS PROCEDURES

BRONCHOSCOPIC PROCEDURES

CAPSULE ENDOSCOPY

CARDIAC CATHETERIZATION

CARDIOVERSION, ELECTRICAL - INTERNAL

CARPAL TUNNEL SURGERY

CHOLECYSTECTOMY, LAPAROSCOPIC

CIRCUMCISION

CORONARY THERAPEUTIC SERVICES

DENERVATION

ELECTRICAL STIMULATION, OPERATIVE

ELECTROMYOGRAPHY and NERVE CONDUCTION VELOCITY TESTING

ENDOSCOPY, SURGICAL (SINUS, ESOPHAGUS, SMALL INTESTINE, STOMA)

ESOPHAGOGASTRIC FUNDOPLASTY

EXCISION CYSTIC HYGROMA, AXILLARY/ CERVICAL

GRAFT PROCEDURES ON MUSCULOSKELETAL SYSTEM (GENERAL)

HERNIA REPAIR (open and laparoscopic)

HYPERBARIC TREATMENT

IMPLANT AND REVISION OF NEUROELECTRODES

IMPLANT COCHLEAR DEVICE

IMPLANT CRANIAL BONE GRAFT

IMPLANT INFUSION PUMP

INSERTION OF TUNNELED INTRAPERITONEAL CATHETER

LAMINOTOMY/ LAMINECTOMY

LAPAROSCOPY OF ABDOMEN, PERITONEUM, OMENTUM

NEPHRECTOMY

OPTIC NERVE, DECOMPRESSION

ORAL SURGERY

ORCHIECTOMY, ORCHIOPEXY

OVIDUCT/ OVARY, LAPAROSCOPY

PTERYGIUM SURGERY

SHOULDER SURGERY/ REPAIR/ REVISION/ RECONSTRUCTION

SKIN GRAFTING PROCEDURES

SPINAL IMPLANT/ PUMP/ ANALYZE

SPINE FUSION

STRESS TEST (THALLIUM, CARDIOLYTE, ETC.)

THORACOSCOPY, DIAGNOSTIC OR SURGICAL

TRANSCATH STENT TO CAROTID ARTERY/ INCLUDING ANGIOPLASTY

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

TYMPANOSTOMY

HOME HEALTH: PLEASE CONTACT COASTAL CARE SERVICES AT 1-833-204-4535.

HOSPICE

HOSPICE INPATIENT

HOSPICE OUTPATIENT

MATERNITY

DELIVERY (SCHEDULED CESAREAN AND INDUCTIONS)

OBSTETRICAL CARE — PRE-NATAL PROCEDURES (Prenatal sonograms do not require prior auth)

ORTHOTICS AND PROSTHETICS

CRANIAL ORTHOSIS

LIMB AND TORSO PROSTHETICS

ORTHOTICS/ PROSTHETICS

PROSTHETIC CUSTOM EYE, SURFACING & FITTING

SHORT TERM REHABILITATION THERAPIES (PT /OT/ ST): PLEASE CONTACT HEALTH NETWORK ONE AT
1-888-550-8800.

THERAPY

RESPIRATORY THERAPY

TRANSPLANT

ALL TRANSPLANT SERVICES, INCLUDING EVALUATIONS

TRANSPORTATION

NON-EMERGENCY AMBULANCE AND AIR AMBULANCE